Optometric Management Tip # 222   -   Wednesday, April 19, 2006
Pupil Dilation: A Tip to Improve Patient Flow

Some tips are true gems and this is one of them, in my opinion. One of the biggest factors in patient flow in an eye care practice is pupil dilation. Itís not that it takes so much time to instill drops or perform the dilated fundus exam; itís the inefficiency of having to see each patient twice. The logistics of moving people in and out of exam rooms and reviewing the details of each case is time consuming. If you typically see 25 patients per day, but you have to see most of them twice, it really adds up!


In order to speed up patient flow, Iíve tried various attempts at instilling mydriatic drops before the doctor sees the patient. Most of these efforts have not worked well, because the cycloplegia that accompanies the mydriasis has adversely affected the accuracy of the refraction. I value clear, comfortable vision too highly to accept any technique that reduces the accuracy of my spectacle and contact lens Rx.

A method that I have been using with much success for over 20 years is to have my technician instill a non-cycloplegic dilating drop during the pretest work-up. I first wrote about this technique in an article published by Optometric Management in 1989, but itís still not used much in our profession.

The non-cycloplegic mydriatic

There is really only one commercially available eye drop that dilates the pupil without causing any effect on accommodation and that is phenylephrine hcl, also known as neosynephrine and other brand names. This is a fairly weak and slow-acting mydriatic drug, but the fact that it does not induce any blur and does not change the refractive state of the eye makes it useful in practice. Phenylephrine comes in 2.5% and 10% concentrations. I use the 2.5% because it has less risk of systemic side effects.

Standard of care

Letís be clear that phenylephrine does not produce as much dilation as tropicamide --- and youíll still need to add tropicamide when indicated for a full view of the peripheral retina.† Phenylephrine alone is not the standard of care for a dilated fundus exam, but most of us do not dilate every patient at every exam.† Of course we all dilate lots of patients, and I donít mean for this topic to lean toward a commentary on how often one should dilate Ė Iíll leave that to each doctorís professional judgment. There are many protocols out there. Some doctors dilate every patient at every visit; some dilate at the first exam and then periodically as indicated by history, symptoms and time intervals; and some hardly ever dilate. It might be said that the standard of care is not really about dilation; but rather about adequately visualizing the fundus. You should always use your judgment and fully dilate when you need to. By having my technician instill the phenylephrine drops before I see the patient, Iím able to obtain a large enough pupil to use a binocular indirect ophthalmoscope or a 78/90 diopter fundus lens on most patients. I will still add a drop of tropicamide when needed, but in many cases, with healthy established patients, the phenylephrine is enough.

Use in practice

The success or failure of this dilation routine is in the little details. Here are some tricks that Iíve developed over the years. I think youíll like this technique if you try it. Iíve never had a spectacle Rx re-make that was attributed to phenylephrine. The pupils are not so big that you have trouble doing a contact lens evaluation during the routine eye exam. A nice bonus is that patients are able to see just fine to select frames and order glasses after the exam.

I have more tips on pupil dilation and Iíll cover them next week.

Best wishes for continued success,

Neil B. Gailmard, OD, MBA, FAAO
Chief Optometric Editor, Optometric Management